Inquest into the Death of Tien Chung NGUYEN

55y · Male·ruptured dissection of the thoracic aorta

Tien Chung Nguyen, a 55-year-old male prisoner, died from rupture of a thoracic aortic dissection during emergency surgery at Royal Perth Hospital. He presented with chest pain and dyspnoea at Wooroloo Prison on 26 November 2010 and was transferred to Swan Districts Hospital where initial investigations (ECG, troponin, chest X-ray) were non-diagnostic. A widened mediastinum on repeat chest X-ray prompted urgent transfer to RPH where CT imaging confirmed type A aortic dissection. He deteriorated on induction of anaesthesia and died despite resuscitation efforts. The coroner found medical care at SDH was appropriate despite delayed diagnosis; the complexity, obscuring medical history, language barriers, and rarity of aortic dissection in ED presentations contributed to diagnostic delay. Prison and emergency response protocols were appropriate. No preventable factors were identified.